Dr. Bender explains the complex answer to a common patient question: what is your rate of cesarean delivery? Learn more about why cesarean delivery rates are higher than in the past, the importance of choosing an obstetrician you trust, and more.
“Redrop: “What’s Your Cesarean Section Rate?” – with Dr. Sam Bender
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Dr. Fox: Welcome to “The Healthful Woman Podcast,” the fastest growing podcast in women’s health. Today’s Monday, April 25th, 2022. Now that the podcast is two-years-old and we’ve picked up a lot of new listeners, we decided to sprinkle in some redrops of prior podcasts. Last week, we redropped a podcast about teaching hospitals. And three weeks ago, we redropped our very first podcast with Emily Oster. Today, we have one more redrop and then, in the upcoming weeks, we have a lot of new podcasts coming.
In today’s podcast, Sam Bender and I discuss C-section rates and why that number may not be so important or at least why it may not be the right question to be asking of your doctor or hospital. We originally dropped this 2 years ago, in May, 2020, and I chose it as one of our redrops for this year. There’s a lot of focus on C-section rates across the country, but I’m not sure it’s as productive as one might think. The thought is that it’s related to the doctor or the hospital, and it is, but it’s also related to the risk factors for C-section in the patients.
For example, if one hospital has mostly young healthy women having five children, on average, they’re gonna have a very low C-section rate. But another hospital with mostly older women having one or two children on average will have a much higher C-section rate. But which hospital is better? You can’t really tell from those C-section rates. Sam and I get into all of that on this podcast and more, and I hope you find it interesting. All right. Thanks, again, for listening, have a great day. See you Thursday on high-risk birth stories.
Welcome to today’s episode of Healthful Woman, a podcast designed to explore topics in women’s health at all stages of life. I’m your host Dr. Nathan Fox, an OB-GYN and maternal fetal medicine specialist practicing in New York City. At Healthful Woman, I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.
Today, we will be talking about cesarean delivery rates with Dr. Samuel Bender. Sam, welcome to Healthful Woman.
Dr. Bender: Hey, good to be here.
Dr. Fox: So, we’re gonna be talking about cesarean delivery rates. And this is something that gets a lot of press, a lot of people talk about it, a lot of women ask us about it. And how do you respond to someone that says, “What is your cesarean delivery rate.”?
Dr. Bender: It’s actually an interesting question. The best way that I now respond is to try to make them define the question for me a little bit better. “Are you asking me about if you have labor? Are you asking me how many patients have scheduled C-sections?” And once they tell me exactly who they’re talking about, then we can begin to sort of take apart exactly what the question means, what the answer actually is.
What I usually turn up doing is trying to individualize it, to say, “A patient like you, a single baby that’s headfirst in an uncomplicated pregnancy,” and then you can answer it. Or you can say, you know, “For you, having twins and two prior cesarean deliveries, this may be the number that you’re looking at as sort of a realistic likelihood that you’re gonna have a vaginal birth versus a C-section.”
Dr. Fox: And I think that touches on a really important point, and particularly when people try to compare cesarean rates either between doctors, between practices, between hospitals, between cities, between countries, whatever it is, is it’s very difficult to compare apple to apple, so to speak. So, if you have one hospital, one practice that takes care of a lot of higher risk women with more risk factors for C-sections, for example, maybe they take care of a lot more twin pregnancies or women who are older, which is a risk factor for C-sections, or women who have prior C-sections, which increases the risk of having one again, their overall rate is gonna be higher but that does not mean they’re providing bad care, they may be providing better care. Or if you have a community which is filled with women who have a lot of vaginal deliveries and then they go to a hospital, their cesarean delivery rate is gonna be very very low. And so, the older data that just compare total cesarean delivery rates was, generally…it wasn’t flawed, meaning it was accurate, but it really wasn’t representative of the question people wanted to know, which is, “Are these people more likely to do a C-section under the same circumstances?”
And one of the solutions that has come out nationally is an attempt to compare apples to apples. And so, what you’ll now hear are cesarean delivery rates for, what they call, the NTSV, which is what you were referring to before, which is N for nulliparous first baby, T for term, meaning, at the end of pregnancy, S for singleton, meaning one baby, not twins, and V for vertex, meaning headfirst. So, in that circumstance, what is the cesarean delivery rate? Typically, in hospitals, it’s in the range of 20% to 25%, that’s where sort of the middle is…
Dr. Bender: That’s absolutely correct. Generally, I assume that, when I’m being asked the question, “What is your cesarean delivery rate?” it’s somebody that actually is pregnant or thinking of being pregnant that’s looking at their own situation. Once again, I think any kind of metric that helps somebody see what their likelihood of having a C-section versus a natural delivery I think is helpful and a good question.
Dr. Fox: Total cesarean delivery rate in the country somewhere around 1 in 3, in the low 30%, and that’s way higher than it used to be 40, 50, 100 years ago.
Dr. Bender: It’s extraordinarily high, especially in urban areas, especially in major medical centers, especially in teaching hospitals the cesarean delivery rate is higher than we’ve ever seen.
Dr. Fox: And why do you think that is?
Dr. Bender: It’s a combination of things. One of the absolute driving forces for it is, what we call, repeat cesarean sections. It isn’t that you’re not allowed, in most instances, to attempt a vaginal birth after a prior cesarean delivery but one of the number one reasons in this country that the C-section rate is rising and will continue to rise is that you now have a cohort of people having babies that have had a cesarean delivery and are either at high enough risk that they choose to have additional cesarean sections or simply choose to continue having C-sections as their safest mode of delivery.
Dr. Fox: I mean, if you look at 100 years ago, the cesarean delivery rate was under 5% in this country. And, at the time, essentially, the only goal in labor and delivery was to have the mother survive delivery and to live through it and be healthy and to be well. And that was not guaranteed at that time.
Dr. Bender: Absolutely not. It doesn’t seem like that long ago, even though none of us were alive then, but, in World War II, they discovered these things called antibiotics. And prior to the antibiotic era, having major abdominal surgery, especially in the setting of childbirth, carried with it an extraordinarily high risk that the mother wasn’t going to survive the procedure. And so, the focus and the training that obstetricians and midwives had in that era was to find ways to get all the babies delivered vaginally. And you were saving mothers in accomplishing this. And that’s, essentially, where a lot of the operative vaginal deliveries were being both perfected, pioneered, and performed because it allowed you to successfully deliver women vaginally and save them from potential death.
Collaterally, you know, you were in an era where some of the babies were going to be damaged or, potentially, not survive the deliveries that were being performed. But the big picture was you were saving the mothers.
Dr. Fox: Right, I mean, before, in the 19th century, in the 1800s, you really wouldn’t do a cesarean delivery unless the mother actually had died. Because the mortality from a cesarean delivery was 100%, women would not survive the procedure. And so, you wouldn’t do one to save a baby, so to speak, you would only do it if the mother died in labor and then you were trying to save the baby. And to think it’s really not such a long time between then and where we are now, where it’s almost the opposite, where, instead of focusing on the risk of the mother and doing anything we could to get her through delivery safely, that’s almost expected as a given nowadays and most of the efforts, in the past 50 years, in terms of labor and delivery have been about improving the outcomes of the babies.
Dr. Bender: Oh, without a doubt. And I see that, actually, in the decision making, that many of my patients now have. When asked a typical question, “What are the risks of having a natural childbirth,” versus, “what are the risks of surgery?” the conversation goes from risks to mother and risks of baby. And many patients, at this time, are making decisions that I believe are based on minimizing any and all potential risk for their baby. And, in many of these settings, I see patients that are willing to accept more and more risk to themselves to accomplish that.
Dr. Fox: And also, some of that is on women themselves who are, as you said, willing to accept more risk. Some of that is due to some of the advanced testing we’ve had also for babies, the idea of fetal heart rate monitoring, which was implemented with the hope of reducing the rate of babies either dying in labor or being born with severe hypoxic brain injuries and developing cerebral palsy and whatnot, they were all instituted, they haven’t been as successful as we would have liked in reducing those risks, but you see so many things going on that it has increased the risk of a cesarean delivery in labor.
Dr. Bender: Without a doubt. Electronic fetal monitoring is both a wonderful thing and a burden. With electronic fetal monitoring, over the years, we’ve changed our nomenclature multiple times but, ultimately, there’s only three kinds of tracings that we ever see. We see tracings that are reassuring, that tell us that the baby is doing well in labor and that the risk of having low oxygen levels, or hypoxia, is quite small. We see tracings that are ominous, that tell us that we need to urgently deliver a baby. And then, unfortunately, we have this interesting gray area in between where it’s not an ominous tracing but the heart rate tracing may not be reassuring. In that setting, as an obstetrician managing somebody’s labor, our goal is to try to find things that are reassuring to allow us to safely continue the labor. Or many times, unfortunately, we find ourselves advocating a cesarean delivery because we cannot get that level of reassurance for the patient. And most of the time that you’re in that area, it’s a true gray zone. The cesarean section, in retrospect, may not have been required.
Dr. Fox: Right, and you don’t really know that moving forward, that’s the hard part, you only know after you did it. And it’s a difficult situation to be in because we know, going into it, that there’s, what’s called, that false positive rate where the fetal heart rate monitoring is, quote unquote, abnormal. And we know that a very large percentage of those babies are still perfectly fine but it’s not always that easy to discern which ones are perfectly fine and which ones aren’t, which leads to a decision that either we have to wait longer and take some risk, potentially, or do a cesarean delivery.
Dr. Bender: Absolutely. When you’re having this moment of shared decision making with your patient and you explain that there is a potential that things could be a problem, it’s nearly 100% of the time that I find that the patient’s unwilling to take that risk and we turn up choosing to do a cesarean delivery.
Dr. Fox: And I think that’s one of the important things, when, you know, women ask me about our cesarean delivery rates or my cesarean delivery rates, I will tell them, I’ll give them numbers, but I always tell them, “The most important thing is do you trust the doctor who’s with you in labor, that he or she is gonna be helping you make decisions that are in the best interest of you and your baby? And what that means is do you have someone who’s patient enough to wait when waiting is the appropriate thing to do but also bright enough to recognize when things aren’t going the way they should.” Because you don’t want someone who’s just gonna bury their head in the sand, also you want someone who’s gonna be patient but someone who also is gonna recognize when there is a potential problem and discuss it with you. And if the answer is, “I don’t trust my doctor,” that’s a big problem and you may end up in a very difficult situation in labor when he or she recommends something and you’re not gonna trust that.
Dr. Bender: You’re absolutely correct. There’s a connection that an obstetrician or a midwife has with a laboring patient that requires that there’s both shared decision making, as well as trust and a priority to the autonomy and the desire of what the patient wants but some kind of an understanding that there’s a trust in the ability and the reasoning of your obstetrician when it comes to having a good connection to be able to labor somebody.
Dr. Fox: What I go over with women is that, whenever someone is having a baby, we really have three goals. The number one goal is a healthy mother, and that sometimes, like we said, that was the goal very early on in obstetrics, frequently to the detriment of the baby because there was no other choice. But I think it can, unfortunately, go in the other direction that sometimes people forget, that the number one priority for us is the mother in labor, that she is healthy. And then the second goal is a healthy baby, obviously. Healthy mother, healthy baby.
The third goal is, usually, a toss-up and an argument between healthy doctor and healthy partner who gets third place and who gets fourth, but healthy mother, healthy baby. And when someone has a cesarean delivery, there’s really two ways that’s gonna happen. The first way is someone’s gonna tell a woman, “You should not even labor,” right, “you need a cesarean delivery instead of laboring.” That’s one possibility. And the second possibility is, “You need a cesarean delivery while you’re in labor,” meaning the plan is changing.
And I think, when you look at cesarean delivery rates, it’s important to break that up because, for example, if I happen to…let’s say I’m well known for doing complicated repeat cesarean deliveries and people only come to me to have cesarean deliveries, well, my rate’s gonna be 100%. But if I have someone in labor, that doesn’t mean her rate’s gonna be 100%. And on the flip side, if you have someone who only takes care of people who are on their fourth baby and they come in and labor, then their vaginal delivery rate is gonna be close to 100%. And so, it’s important to try to break that down, if it matters, what the rate of your provider is.
Dr. Bender: And one of the classic ways of being able to break it down is to, on a very personal level, individualize it for a particular patient when they come and they want to know what their chances of having a natural delivery are. And, on a more global level, just knowing what question you’re really asking is always a challenge. And so, when patients are just globally talking about C-section rates, you can answer it either with information that you think appeals to them, that, “For a patient in your circumstance, this is what our practice, or me personally, what my C-section rate might be.” And part of it I think is an expectation of what should their risk of C-section be, you know, which is a very different question, actually.
Dr. Fox: Right, and it depends on who they are, like you said, it really needs to be individualized. For example, so, when Sam and I were discussing this topic before the podcast began, we were actually curious what our cesarean delivery rate was in our practice. We had a pretty good guess of what it was, so, we asked Mike Silverstein, who tracks all of our statistics, and, over the past 12,000 deliveries, our overall cesarean delivery rate is 32%. But if you look at women who are actually laboring, meaning they’re trying to deliver vaginally, it’s only 12%. And that’s a very big swing. And so, if you told someone, “My cesarean delivery rate is 32%,” or, “my cesarean delivery rate is 12%,” those sound like very different practices but it’s actually the same practice. And that’s because we do have a lot of women who are not really candidates to labor because of either certain types of twins, although we do labor a lot of twins, or people coming for repeat cesarean deliveries, or people transferring because they have a placenta previa, or some other reason that they specifically come to our practice.
And so, I always encourage women, when they’re asking about cesarean delivery rates, like you said, what exactly are you asking? Like, what do you wanna know? And if they wanna know, “What is the chance I’ll have a C-section while I’m laboring?” Okay, in our practice, it seems to be about 12%. And again, that could vary also based on what is the makeup of your practice. But that’s a very different number than the overall cesarean delivery rate.
Dr. Bender: No, and I think you touched on a lot of points that are absolutely key in how you answer that question for your patient.
Dr. Fox: And one of the things that we’ve seen over the years, particularly you because this is one of the reasons you get a lot of referrals, is, since the cesarean deliver rate has gone up and, as you said, there is this cohort of women who’ve had prior cesarean deliveries, we now see a lot of women who come to us specifically for a cesarean delivery. For example, they’ve had two or three prior cesarean deliveries and their doctor either said, “You can’t have any more,” or they just are thinking about how many more and they come to us either before they get pregnant about what is the likelihood they could have a safe delivery, this is their delivery on their fourth or fifth kid, or they’re already pregnant and they just want us to deliver them. And we’ve had hundreds of women who have come to us in this circumstance, over the years.
Dr. Bender: It’s actually a group of patients that I enjoy I find challenging to be able to deliver. Over the years, I take pride in the fact that we’ve had so many good outcomes with patients that, potentially, were looking at very high risk surgery, especially the patients that have placentas covering the cervix called placenta previa or even more satisfying are the patients that we’ve successfully guided through pregnancy and delivery and turned up with healthy moms and healthy babies in a setting where, in a previous pregnancy, that wasn’t their outcome. Or they may have had, you know, something catastrophic, like a uterine rupture, in a prior attempt at a natural delivery after a cesarean and, this time around, more safely taken through pregnancy and delivered by safe cesarean delivery.
Dr. Fox: Right, and how do you answer the question that I’m sure you get all the time, how many cesareans can one person have?
Dr. Bender: It’s an excellent question. Typically, I start by delving a little bit into their history and finding out whether or not they’ve had additional complications at prior deliveries. I love reviewing, you know, previous operation reports to see, you know, what sort of issues might also complicate a future delivery for them but, for the most part, I tell them, “You’re always one C-section behind finding out how you healed from the last one.” And so, we’re not perfect, we have new tools to be able to evaluate some of these things by measuring what the uterus looks like in between pregnancies, we can always diagnose where the placenta is going to be in pregnancy, but that’s already too late. If you’re talking about preconception counseling, you can tell people the likelihood that they’re going to have a placenta in the wrong place and what sort of things might happen but you can’t guarantee that they’re going to be the 95% plus where that isn’t the story.
So, typically, I find myself telling a patient, after three, you know, especially after four cesarean deliveries, that they probably have hit a maximum of their risk already. This is what their risk is, unless they have other complications that have happened at prior surgery, this is where their risk is, and they don’t get to pick where their placenta is going to be. So, that’s something that will have to be determined once they have chosen to accept they’re going to be pregnant again. And so, some of the risks can’t be determined. The short answer is there isn’t, you know, a finite number of pregnancies or deliveries, we don’t live, you know, sort of at a point where we say, “After three C-sections, you have to do this and, after five, you have to stop.” If a woman is determined to build a larger family, if she wants to accept the risk of another pregnancy, it’s overwhelmingly likely that we can take her through her pregnancy and get a full-term or near-term delivery safely, you know, for that patient.
To date, the most C-sections I’ve performed on a single patient is 11. It sort of boggles my mind, the potential of attempting to raise 11 children, let alone mode of delivery for them. But her delivery were, each and every one, uncomplicated, so, there was nothing else that we were adding to the mix by saying, “You could get pregnant again with the exception of you’re a little bit older now, there may be other factors of being older that are going to impact on your pregnancy and you still don’t get to pick where your placenta is and you may still be the 3% to 5% where the placenta is not in the correct place, which would make your pregnancy, potentially, far more complicated.”
Dr. Fox: To clarify what Sam’s talking about is one of the main risks of having multiple cesarean deliveries is a condition called placenta accreta where the placenta is, basically, stuck, so to speak, to the uterus, it’s adherent. And so that, after delivery, it does not separate and come out. And when that happens, the main treatment for it, typically, is a hysterectomy, removal of the uterus, and, during that operation, there’s a high risk of requiring massive blood transfusions being emitted to the intensive care unit, potentially damage to other organs. So, that that situation, when there’s a placenta accreta, is a much higher risk type of delivery.
And, for someone with a history of multiple cesarean deliveries, let’s say three, four, or five, the risk of placenta accreta greatly varies based on where the placenta is located. If the placenta is located low in the uterus, which we call placenta previa, the risk of having that placenta accreta is over 50%, more women will have it. Whereas, if the placenta is located higher up in the uterus, it’s probably under 5%, it’s not such a high risk. And so, what Sam was saying is, before someone’s pregnant, if their placenta ends up in a good spot, the likelihood is they’ll have a mostly uncomplicated pregnancy and delivery. And if they’re unlucky enough that the placenta ends up in the wrong spot, so to speak, it’ll be a much higher risk delivery, they’ll still likely get through it safely but it’ll be much more complicated.
And so, there are tables you can use and look at and give people the numbers. And that’s one important thing. And just like he said, I never give people the number either, it depends sometimes on each delivery. If someone’s fourth C-section was extremely difficult, it took a very long time, there’s a lot of scar tissue, it took multiple people multiple hours to finish it, well, then she’s at a much higher risk in the next pregnancy than someone who had a very uncomplicated cesarean delivery. And so, I always tell people, “You have to take it one at a time. Just like you have your kids one at a time, sometimes two, you have your cesareans one at a time as well.” But it is important to see people who have experience doing these operations. They’re not always straightforward, they require experience and skill.
Dr. Bender: In medicine, we train to do procedures and we do them by repetition, learn the steps. And many times you will find that, you know, still today we’re doing the cesarean delivery in the exact same steps, one after another, that was taught to us and taught to our teachers a generation earlier in medicine. And with some of these surgeries, it requires frequently a different approach. You may not be able to do the steps in the proper order, you may have to do additional surgery to obtain the proper area to incise the uterus and deliver the baby, you may need to do additional procedures to be able to know that, if there is excessive bleeding, that you can control it by identifying where the major blood vessels are, this may require removing a significant amount of scar tissue, even before the baby is born. On a creative level, I find these surgeries interesting. My major goal when I undertake cases like this is to have proper pre-operative evaluations to know what you may be looking at in terms of where the placenta is, whether the accreta is present. And a whole lot of planning to make certain that you have appropriately skilled teams from pediatrics, if the baby is going to be delivered early from anesthesia, if there’s a potential for larger blood loss than typical, and even from additional people that are specifically skilled in doing hysterectomy in difficult circumstance, in critical care-type medicine, or, in our institution, we’re able to rely on people with extensive surgical training from the oncology department. The bladder and the bowel, you know, can be involved in adhesions. In the area that we operate, we need to know that, if there’s a question of damage or known damage to these organs, that we have appropriate team of people available to provide the proper surgery that patient requires to be able to allow her to be a healthy mom at the end of our story as well.
Dr. Fox: Right, and there have been multiple studies that have shown that, for these types of high-risk deliveries, whether multiple cesarean deliveries or placenta previa, placenta accreta, that outcomes are markedly better if they’re prepared for, if they’re planned in advance, if there’s a team approach beforehand, if everyone knows, you know, this delivery is coming up, who this woman is and, like you said, all the services are in place and we’ve done the proper pre-operative preparation. Including whether it’s ultrasounds, blood testing, you know, counseling, getting other services involved, having it scheduled on the right time, the right day, with the number of people, having availability. And outcomes are better when that happens.
And one of the more satisfying things that we have in our field and in our practice is when someone comes and says, “I was told I can’t have any more children but I wanna have more children,” and you’re able to help them do that safely is tremendous. You helped them have an opportunity to have another child in this world, which is what they want, which is really wonderful.
Dr. Bender: I completely agree. I’m very fortunate, I practice in New York City. Essentially, in walking distance, if you’re a good walker, you can get four of the top medical centers in the world on our little island called Manhattan. And so, we have institutions that provide all of these care, they’re all integrated and they’re right here. And so, for this geographic area, we can provide a service in smaller community hospitals or even smaller medical centers where they don’t have all the various different ancillary services available 24/7, you know, that we can do this in a proper way, a planned way, a safer way.
Dr. Fox: So, this was a great conversation about cesarean delivery rates and about, what we call, “high-order cesarean deliveries.” And again, to review, it is important, when discussing cesarean delivery rates, to try to be more precise and exactly what is the rate we’re looking for, if trying to compare between hospitals or doctors or practices or whatever it is. And, obviously, trying to find a level of trust with whoever’s taking care of you that he or she, if they recommend a cesarean delivery, it’s something that’s in your best interest, in the baby’s best interest.
And then if the situation does arise that you’ve had prior cesarean deliveries or multiple prior cesarean deliveries, that it’s not necessarily hopeless, it’s not necessarily a situation when you can’t have more, but to seek out somebody who has experience in this and is able to have a team approach and proper care to maybe give you an opportunity to have another child safely for you and the baby.
Dr. Bender: I can’t underestimate the importance of having that conversation potentially before you got pregnant, with your doctor, to find out exactly what your issues are. Going backwards, you know, asking the question, “What is your cesarean delivery rate?” I think ascertaining where where the patient is coming from, “what sort of answer are you looking for?” is very important. You know, “What is your C-section rate for somebody like me?” I think is probably the question that you need to ask.
Dr. Fox: Great. Sam, thanks for coming on Healthful Woman. Have a wonderful day, everyone.
Dr. Bender: Thank you.
Dr. Fox: Thank you for listening to “The Healthful Woman Podcast.” To learn more about our podcast, please visit our website at www.healthfulwoman.com, that’s H-E-A-L-T-H-F-U-L-W-O-M-A-N.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at firstname.lastname@example.org. Have a great day.
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